Bypass Surgery Versus Stenting for the Treatment of Multivessel Disease in Patients With Unstable Angina Compared With Stable Angina

Abstract

Background-Earlier reports have shown that the outcome of balloon angioplasty or bypass surgery in unstable angina is less favorable than in stable angina. Recent improvements in percutaneous treatment (stent implantation) and bypass surgery (arterial grafts) warrant reevaluation of the relative merits of either technique in treatment of unstable angina. Methods and Results-Seven hundred fifty-five patients with stable angina were randomly assigned to coronary stenting (374) or bypass surgery (381), and 450 patients with unstable angina were randomly assigned to coronary stenting (226) or bypass surgery (224). All patients had multivessel disease considered to be equally treatable by either technique.Freedom from major adverse events, including death, myocardial infarction, and cerebrovascular events, at 1 year was not different in unstable patients (91.2% versus 88.9%) and stable patients (90.4% versus 92.6%) treated, respectively, with coronary stenting or bypass surgery. Freedom from repeat revascularization at 1 year was similar in unstable and stable angina treated with stenting (79.2% versus 78.9%) or bypass surgery (96.3% versus 96%) but was significantly higher in both unstable and stable patients treated with stenting (16.8% versus 16.9%) compared with bypass surgery (3.6% versus 3.5%). Neither the difference in costs between stented or bypassed stable or unstable angina ($2594 versus $3627) nor the cost-effectiveness was significantly different at 1 year. Conclusions-There was no difference in rates of death, myocardial infarction, and cerebrovascular event at 1 year in patients with unstable angina and multivessel disease treated with either stented angioplasty or bypass surgery compared with patients with stable angina. The rate of repeat revascularization of both unstable and stable angina was significantly higher in patients with stents.

A comparison of percutaneous coronary intervention and surgical revascularization after fibrinolysis for acute myocardial infarction. Insights from the InTIME-2 trial

“…Despite these baseline differences, mortality rates were similar following both revascularization procedures. Also, similarly to what has been found in patients with stable angina or non-ST-elevation acute coronary syndromes [1,5,15,16], an apparent benefit of CABG in our study was restricted to reduction in non-fatal cardiac events -reinfarction, and hospital readmission for acute ischemia. Moreover, the differences between the groups, regarding isolated non-fatal events, did not reach statistical significance when adjusted models were applied.…”

“…The suggestion that surgery performed at least equally well to PCI in selected patients referred for revascularization early after MI is both clinically relevant and reassuring in the context. Thus, randomized trials comparing CABG and PCI have not enrolled patients with complex forms of coronary disease such as left main disease and refractory post-MI angina [13][14][15]21,22]. Moreover, in these studies very often cardiologists, interventionists and surgeons have difficulty reaching final consensus in terms of equal treat ability.…”

And the Answer Is, It Doesn’t Much Matter

“…Patients with unstable coronary syndromes are in general "sicker" than those with stable disease, at least in regard to factors such as plaque stability, endothelial dysfunction, and the frequency of current events. However, the marked improvement in outcomes of both coronary bypass graft surgery and percutaneous intervention, as documented in this study, 10 shifts our focus toward recognizing the fact that unstable angina provides "a window of opportunity" rather than an "open window from an upper floor." Moreover, these encouraging data from the ARTS trial 12 suggest that the inherent risk posed by "instability" is much less than previously thought.…”

“…These observations form the backdrop for the article by de Feyter et al, 10 which studies the importance of unstable versus stable angina within the randomized Arterial Revascularization Therapies Study (ARTS) trial of patients with multivessel disease who were randomized to either stent implantation or coronary bypass graft surgery. The definition of unstable angina is crucial in any such analysis and included Braunwald IB, C to IIIB, and C (Table), 11 whereas all other categories came under the rubric of stable angina.…”

Prognostic Factors and Longterm Survival of Myocardial Infarction Patients, Complicated by Early Recurent Angina and Renal Function Decrease

“…В ходе дли-тельного наблюдения за пациентами с РПС, было выявлено до 40% летальных исходов, в связи с чем многочисленные исследования и существующие рекомендации рассматривают РПС в качестве одного из клинических показаний для проведения чрескож-ного коронарного вмешательства (ЧКВ) [4,5]. Так, ранняя ЧКВ у пациентов с РПС более благоприятна по сравнению с медикаментозной терапией, при этом риск осложнений и поздних рестенозов оказывается сопоставим с риском при стабильной стенокардии [6]. Пациенты с РПС, лечившиеся консервативно, имели неблагоприятный прогноз в течение первого года наблюдения, при этом риск развития повтор-ного инфаркта, по разным данным, составил от 13 до 86% [7].…”